Pre-Exposure Prophylaxis (PrEP) Screnning for Substantial Risk and Eligibility

Client Information

General ID

Initial Client Visit

PrEP ID

Name

State

Phone 1

Phone 2

DHIS2 ID

Sex

Sex Other

Age

State/ Region of birth

Township of birth

Main Risk

Sub Risk

Facility Information

Facility Name

Virtual KPSC

Navigator Code

Persion Completing Form

Sexual and Drug Injection Core Risk Classification

1. Do you consider yourself male, female,transgender,or other?

Other,Specify

Do you have sex with

Have you exchanged sex as your main source of income in the last 6 months?

In the last 6 months, have you injected illicit or illegal drugs?

Screnning for Substantial Risk for HIV Infection

1. If client is sexually active in a high HIV prevalance population PLUS reports ANY one oth the below in the last 6 months.

(a) Reports vaginal or anal intercourse without condoms with more than one partner

(b) Has a sex partner with one or more HIV risk:

(d) History of use of post-exposure prophylaxis (PEP)

2. If client reports history of sharing injection material or equipment in the last 6 months.

History of sharing injection material or equipment.

3. If client reports having a sexual partner in the last 6 months who is HIV positive AND who has not been on effective * HIV treatment ) ( * the partner has been on effective * HIV treatment)

History of HIV-positive sex partner not on effective treatment

4. Requesting PrEP?

Key Population Classification (an individual can belong to more than one category)

if client answers "Male" to question 1 and answers "Men/TG W" or "Both men and women" to question 2,then categorize as man who has sex with men (MSM)

if client answers "Transgender TG W" to question 1, then categorize as trangender( TG W)

if client answers "Yes" to question 3,then categorize as sex workers(SW)

if client answers "Yes" to question 4,then categorize as person who injects drugs (PWID)

if client is not transgender woman (TG W) and answers "No" or "No response" to questions 2 to 4, calssify as None Key Population

Final Classification

Other Specify

Recent Exposure to HIV

In the past 72 hours, have you had sex without a condom with someone whose HIV status in positive or not known to you, or have you shared injection equipment with someone whose HIV status is positive or unknown to you?

In the past 28 days , have you had symptoms of a cold or flu, including fever, fatigue, sore throat,headache, or muscle pain or soreness?

Reason

PrEP Elibibility

HIV non-reactive/negative

Test Date

Result Receive Date

Test Result

Reative Date

Confirmation result

HIV substantial risk

Has no suspicion of acute HIV Infection?

PrEP Eligible

Reasons for Declining PrEP

Does not think it necessary

Reason for does not need

Concerns about side effects

Concerns about what others might think

Concerns about time required for clinic follow-up

Concerns about safety of medication

Concerns about effectiveness of medication

Other

Referred for PEP evaluation

Referred for HIV confirmation

Referred for PCR / HIV ag test or Follow-up re-testing

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